tapering opioids

NPS Medicinewise. 5 steps to tapering opioids for patients with chronic non-cancer pain. 2020.

Step 1: Explore the Patient’s Expectations

• Objective: Understand patient’s readiness and concerns about reducing opioid dose.
• Approach:
  • Engage in reflective listening.
  • Use open-ended questions to explore patient’s knowledge and beliefs about opioids.
  • Specific Questions:
    • “What do you know about the long-term use of opioids?”
    • “What worries you about reducing your opioid dose?”
    • “What are your daily functional goals and how do opioids impact these?”
• Assessment Tools: Utilize the ‘5As’ framework:
  • Analgesia: Assess pain relief provided by opioids.
  • Activity: Determine impact on daily functions.
  • Adverse effects: Inquire about side effects like constipation, drowsiness.
  • Affect: Explore mood changes, signs of depression.
  • Aberrant behavior: Check adherence to prescription, signs of misuse.

Empower the Patient

• Strategy: Build a collaborative relationship for effective opioid management.
• Implementation:
  • Set transparent treatment expectations from the onset regarding treatment length, dosing, and exit strategy.
  • Emphasize the shared decision-making process, making the patient an active participant.

Provide Reassurance

• Communication: Reassure patients that tapering will be supervised and supported.
• Plan:
  • Follow guidelines for gradual tapering.
  • Regularly review progress.
  • Assure patients that abrupt cessation is not the approach.

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Step 2: Review Pain Management Plans

• Goal Setting: Assist patients in setting specific, meaningful, and achievable goals.
• Self-Management Strategies:
  • Cognitive Behavioral Therapy (CBT) for realistic goal setting and activity pacing.
  • Mindfulness and acceptance interventions.
  • Physical therapies to improve function.
• Multidisciplinary Approach:
  • Coordinate with specialists and allied health professionals.
  • Address biopsychosocial aspects of chronic pain.
  • Adapt plans when multidisciplinary support is unavailable, focusing on patient motivation and gradual opioid reduction.

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Step 3: Develop a Tapering Plan

• Personalization: Tailor the tapering plan to individual needs and goals.
• Tapering Strategies:
  • Fast taper for short-term opioid use or unmet treatment goals (10%-25% weekly).
  • Slow taper for long-term use without significant pain/function improvement (10%-25% monthly).
  • Regular monitoring to adjust the rate based on patient response.
• Support: Consider specialist advice for complex cases or when switching opioids.

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Step 4: Expect Some Withdrawal Symptoms

• Anticipation: Prepare for likely withdrawal symptoms during tapering.
• Management:
  • Use medications like clonidine to manage symptoms such as nausea, diarrhea, muscle pain.
  • Educate about possible temporary increases in pain or sensitivity.

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Step 5: If in Doubt, Seek Support

• Resources: Engage multidisciplinary teams for complex tapering cases.
• Risk Assessment:
  • Identify patients at high risk of tapering dropout due to factors like depression or high opioid doses.
  • Provide additional support for these patients.

Conclusion

• Comprehensive Approach: Integrate early tapering discussions, evidence-based guidelines, and open patient communication.
• Success Criteria: Define success based on achieving functional and social goals, not just opioid cessation.
• Flexibility: Be prepared to modify the tapering plan based on patient responses and challenges